Prophylactic Antibiotics
The basis for administration of prophylactic antibiotics in patients with AP is to prevent infection in those who develop necrotizing AP. The mortality in patients with necrosis is up to 20% compared with 5% mortality in those with edematous or interstitial AP [68]. Once infection complicates necrosis, mortality increases to 30–40%. Therefore, prophylactic antibiotics would appear to be a reasonable therapeutic approach. However, it has been shown to be ineffective in a Cochrane Database systematic review by Villatoro et al. [69], who found that there was no benefit to antibiotics for preventing pancreatic necrosis infection or decreasing mortality.
Subgroup analysis of patients who received imipenem showed a significant decrease in pancreatic infection, but no significant reduction in mortality. Antibiotics should only be administered to patients early in the course of AP who have suspected biliary sepsis or show evidence of extrapancreatic infection (i.e. urinary tract infection and/or positive blood cultures). In addition, antibiotic treatment should be used for suspected or diagnosed pancreatic or peripancreatic infections in the later phase (one to two weeks) after onset of disease. The role of antibiotics in this phase is to allow the organization of the necrosis as well as delaying surgery, usually until four weeks, as this is associated with decreased mortality compared with early intervention. In addition, delay and use of antibiotics may allow for application of less invasive drainage procedures. In addition, antibiotic therapy alone can effectively treat a subgroup of patients with infected necrosis [70,71]. An initial report by Runzi et al. [71] of nonsurgical treatment of 16 patients with severe AP with infected pancreatic necrosis (IPN), treated only with an antibiotic regimen adapted to bacteriology and nonsurgical therapy, reported a 12% (2 of 16 patients) mortality rate. Six recovered without further complications and 10 patients developed single or multiple organ failure. This study placed a wedge in the concept that all patients with IPN needed immediate open pancreatic surgical drainage. The currently accepted management of patients with IPN is that early in their course they can generally be managed nonsurgically with antibiotics in the initial stage and that antibiotics alone can also be definitive therapy. The second concept is that surgery can be delayed, which allows the operative intervention to be performed electively and less invasively.
Nutrition
One of our goals in treating patients with AP is early oral feeding. This should commence as soon as the patient is hungry and ideally when they are not vomiting and have improving nausea and abdominal pain. Oral feeding is a critical foundation of our therapeutic regimen. It maintains small bowel integrity thereby decreasing bacterial translocation. Early enteral nasogastric tube feeding does not reduce infection or death compared with oral feeding at 72 hours. In studies by Bakker et al. [72] and Cote [73], over two‐thirds of the patients tolerated an oral diet after its initiation at 72 hours after randomization, showing that starting an oral diet at 72 hours is not harmful to the patient. In patients with moderate or severe AP, early oral refeeding (defined as when patients are hungry and initiated when clinical and laboratory parameters resolve) is safe and may shorten hospitalization compared to conventional oral refeeding [74]. Vaughn et al. [75] in a systematic review of early (<48 hours) versus delayed (>48 hours) feeding in patients with AP found that adverse events secondary to early feeding did not increase. In these patients with mild to moderate AP, it may also reduce the length of hospital stay [75]. Their early nutrition group included oral as well as tube feeding.
Oral feeding intolerance, defined as relapse of symptoms following oral feeding, occurs in one of six patients with AP [76]. Predictors are complicated or severe disease reflected by presence of pleural effusion and/or (peri)pancreatic collections. If patients have oral feeding intolerance, enteral nutrition (EN) can be initiated with either nasogastric or nasojejunal feeding, as they have similar safety and efficacy. This should start early (<48 hours) in the course of severe AP, but should be delayed for 72 hours in patients with mild to moderate AP to determine if they can tolerate oral feeding. Infusion is with polymeric formula. Low rates of infusion possibly decrease bowel permeability but our goal should aim to meet patients’ caloric demands. EN should be started prior to 48 hours in patients with severe pancreatitis, especially those who are intubated. Khalid et al. [77] showed that the benefits of early feeding were more evident in the sickest (treated with multiple vasopressors) ICU patients.
Bakker et al. [78] reported a meta‐analysis of 165 individuals from eight randomized trials. The cohort was divided into those who received EN within 24 hours of admission and those who received EN after 24 hours of admission. Those receiving EN within 24 hours of admission had decreased organ failure (42% vs. 16%; odds ratio 0.42) and reduction in the complications of IPN and/or organ failure. There was no difference in mortality, and therefore the earlier the initiation of EN, the better for the patient with severe AP. However, the benefits of EN begun within three days could reduce the risk of secondary infection and improve the nutritional status of patients with AP [78].
Overall, EN should be utilized over parenteral nutrition in patients with AP. EN has a multitude of advantages over parenteral nutrition, including avoidance of catheter‐related sepsis, lower cost, maintenance of gut barrier function, and decreased bacterial translocation, a critical mechanism in developing infections in AP patients. EN, compared with parenteral nutrition, results in reduction in the risk of total and pancreatic infectious complications and risk of death [79,80].
Post‐discharge Cholecystectomy
In addition to treating the acute episode of pancreatitis, we need to focus on decreasing the possibility of the patient’s readmission, shown by Munigala et al. [81] to be 14%. The factors that have been associated with increased readmission are shown in Table 1.7. Symptoms upon discharge that have been shown to be associated with increased rate of readmission include inability to tolerate a regular diet and need for pain medications [82]. Cholecystectomy on index admission for acute biliary pancreatitis reduces rates of readmission [82].
Table 1.7 Factors associated with increased readmission rates.
Source: adapted from Munigala et al. [81].
| Patient: alcohol and substance abuse Increased comorbidities (increasing Charlson comorbidity index) Severe pancreatitis: association with pseudocyst, necrotizing pancreatitis Discharge to extended care facility (not home discharge) Biliary pancreatitis not undergoing cholecystectomy on initial admission: note that cholecystectomy on index admission for acute biliary pancreatitis reduces rates of readmission |
The Dutch Pancreatitis Study Group followed more than 600 patients after an episode of AP and found that recurrent pancreatitis developed in 117 (17%). This was more common in those with alcoholic or idiopathic or other etiologies compared with biliary disease. In addition, recurrent pancreatitis was more common in smokers and those who had experienced necrotizing pancreatitis. They reported that smoking was the most important factor for recurrent acute pancreatitis (RAP) [83]. The severity of recurrent compared with initial episodes of AP was reported by Lee et al. [84] and Mallick et al. [85]. Lee et al. found that RAP was associated with zero mortality compared with 4.7% mortality in initial episodes. Prior AP episodes had a decreased risk of severe disease (i.e. multisystem organ failure) [84]. This observation